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This is a challenge to conventional wisdom. Meet Rose Oldham, pictured here with her GP Dr Bhatti, and our Practice Manager Lynn at my surgery donneybrook Medical centre.
I met Rose as her Practice nurse a few months ago, when up popped the dreaded tick box on the clinical records system Alert:‘Frailty’ in front of me. A wonderful 82 year old lady with normal body habitus who bounds energetically into the clinical consultation room, carries a healthy glow, and a smile and proceeds to tell me what keeps her fit and well. Rose has a loving family, and for many years cared for her husband with Parkinson’s. She lives on her own now, and is determined to make the most of life, in the form of living and not just waiting for ‘old age’. Rose has a twinkle in her eye! She has recently fulfilled one of her lifelong ambitions to do a skydive. Not satisfied with this achievement, she tells me to watch this space, as she may yet complete a ‘wind walk’ an experience for her that would count as ‘one of life’s greatest aerial adventures’. Here is Rose pictured in all her glory!

Needless to say, none of this rich information is contained in the electronic records. Time to ask why?
The tapestry of information provided by Rose sets the scene for a truly holistic discussion around well-being. To coin a phrase by my mentor Heather Henry, this discussion leads to an ‘asset based approach to nursing care’. Rose is not a lady without any medical issues that is indeed why she has come to see me today. She has Angina, hypertension, she requires a medication review. However the bio- medical model of care labels her as ‘frail’ and the computer system asks me to initiate a conversation around her needs rather than her strengths.
Here is the official definition of frailty from the British Geriatric Society:What is frailty? Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Older people with frailty are at risk of unpredictable deterioration in their health resulting from minor stressor events.
Whilst I do not question the evidence around frailty, and indeed we must look closely at the quality of health and social care provision for vulnerable groups, I want to challenge the application, the assumptions and the deficit based model of care. Are we a health service or just an illness service?
How can we encourage health creating practice, when systems, policies and frameworks are designed purely on people’s deficits? Whilst it is extremely important to prevent unplanned hospital admission, and improve the quality of care we provide for older generations, it is of equal importance that we focus on what keeps people well. We have an array of good quality evidence for this, but we do not universally apply this in practice. Why?
Over the years, multiple frailty screening tools have been developed, refined and utilised for risk assessment and epidemiologic study. I believe the utility of these screening tools in the clinical setting are limited, and as Rose clearly demonstrates old age itself does not define frailty.
This is not a single story. Up and down the land, we meet greet and see people with strengths, gifts and attributes. But do we really see them? Perhaps we are not having the right kind of conversation. As cormac Russell, pioneer of asset based approaches states: we need to focus on what’s strong, not just what’s wrong. This does not mean we ignore problems, or risks. In Rose’s case, I know my GP was genuinely concerned about her safety for a sky dive, given her medical history of angina; however this was stable, and carefully negated through the power of conversation, mutual exchange, and a focus on well-being. Personal values, preferences and goals should trump over policy based practice every time. As a general practice nurse, I learned very quickly to move beyond the security of the tick box, the framework, the guideline… and to see people for who they are, and not what the system dictates they should be.
We must start from a position of strength, moving away from a culture that just deals with needs and problems. In our area, we have an award winning Healthier at home project. This combines the skills of a multidisciplinary team who work collaboratively to enable older people who really need support. This is working well, and takes a health creation focus, that sits side by side the traditional medical model of care.
The ‘Building bridges, breaking barriers’ report looked at existing integration across health and social care and the impact this has had for older people. GP magazine Pulse recently reported their concerns around the unplanned admissions designated enhanced service. ‘’ analysis of official figures showed that GP practices that devise care plans for the majority of their most vulnerable patients have higher rates of unplanned admissions.’’
We need to get this right for our future, and the stability of our beloved National HEALTH SERVICE. Yes, tap into the good, balance the big data with the stories, with what really matters to individuals, communities, families. Age UK’s vision is for a world where everyone can love later life. They achieve this by’ inspiring, supporting and enabling’ – a motto we should all adopt in general practice.
As many will continue to fill in their frailty index… I am off to start a Feisty Folk register, inspired by local people who have amazing strength, have overcome adversity & can teach us professionals a thing or two about life!
This blog was inspired by the all the red devils out there! The young at heart. Rose Oldham, Zulf Bhatti, Jocelyn Ward, Margaret Murphy, Ian Kenworth Heather Henry, john Walsh, and Lynn Wilkinson.
Louise Brady
Practice nurse, Clinical Development Lead Practice Nursing, NHS Manchester CCG’s, GPN advisor NHS Alliance, National Executive.Linkshttp://www.pulsetoday.co.uk/news/commissioning/commissioning-topics/emergency-admissions/gp-care-plans-to-prevent-hospital-admissions-not-effective-warns-cqc/20032297.articlehttp://www.pulsetoday.co.uk/news/commissioning/commissioning-topics/emergency-admissions/unplanned-admissions-des-is-failing-to-reduce-emergency-activity/20031497.article

What if public health nurses helped people facing disadvantage to get back into work? Is this a legitimate role? How would that happen? Why is it important?This week a mum I know from my social innovation work got a cleaning job. Big deal. Well yes actually. I’ve known her for about 2 years and she’s helped me in my work. I’ve given her a character reference, helped her with her CV and spent time talking to her about her progress. She’s been out of work for several years, she has three children and she is separated from the father of her children. As well as money, this is also about something more important- her own self-esteem and control over her own life.
I didn’t set out specifically to get people back into work but it has become a natural consequence of my social innovation work. As I sit with people from disadvantaged communities, they tell me about themselves and I watch how they live their lives. Because I practice a strengths-based approach I notice what they are good at and then I tell them. The effect of a health care professional doing this seems to stir self-belief. Sometimes they are not ready to hear it and, sometimes having been told (often by their own families) that they lack intelligence or are not good at anything, they don’t seems to have the psychological processes to deal with praise. But I persist.And then I issue them a challenge. I need them to help me. Generally by this time, we have built mutual respect and they don’t want to let me down. And I leave them to think about it and I give them an out if they feel they can’t cope with it. Few seem to take this option and they then have a point to prove.
The challenge relates to them demonstrating their strength, overcoming what they perceive as a weakness and building their confidence. This is about growing community resilience so they can resist the severe disadvantages that they meet every day. When someone who hasn’t worked for years gets a job, their peers start to believe it’s possible. It becomes a snowball effect and the whole community starts to notice.In contrast, I aim to make myself redundant as soon as possible. The community know when I start that I will move on, so I don’t create dependency, but I always tell them I’ll be there for them whenever they need me. Few believe this until they see it, but that’s captured in another blog on the New NHS Alliance website called the Hokey-Cokey theory of community involvement. Please look it up if you can. So for A, his challenge was severe social anxiety. I invited him to a charity night at a local working man’s club. I am a trustee for that charity and I said I needed his support. Needing him is important- he was also one of the few I’d met that had run a community group before. I said I’d get the ticket as it was my treat for all the hard work he was putting in, and several others were going who were working alongside me that he really liked. And I sat and waited on the door so mine would be the first face he would seeHe looked anxious as he appeared in the doorway. He was wearing a shirt freshly purchased from the charity shop. And he said ‘I’ll just be five minutes’ and I thought ‘I’ve lost him’. But he gathered himself and came back in. After that night he wrote a blog in which he said that it was the first time that he had been out socially in 10 years. Social isolation is rife in such communities-and not just in the elderly.
A now volunteers not only in his community but also with a national foundation that supports severe and multiple disadvantage. He goes to London alone and meets with strategic thinkers in health inequality. He narrowly missed out on a job recently, but he will get there. I believe in A, who knows more things about addressing inequality than I ever will, because he’s lived through it. He’s a different man to the guy who literally had to be dragged in by a mate to meet me.D is a mum I know. She barged into our project and was in danger of putting at risk what I was trying to do. I had to tell her to back off. She told me I was too posh to be accepted in this community and only local people like her could do it. So I told her she was right and I did need her help but not in the barging in sort of way. I noticed that she had events management talent. Meanwhile I was working with the local GP surgery, telling them that they should start thinking of the community as a source of help and not just a source of insatiable demand. The surgery boss laughed heartily at this, so I said ‘why not let the community organise a party to celebrate the 8th anniversary of the founding of the practice?’ The boss said ‘ok find me the help’. So I did. I asked D and she not only organised the party she also organised a successful community event about keeping well in winter. The surgery boss gave her a job after that. He no longer laughs at my suggestions.H is clearly destined for nursing. But H is a mother of 3 and has no qualifications to speak of. So I said to H that the first step might be to consider becoming a health care assistant and that I’d introduce her to one so she could see if it was for her. She backed away at this. I asked D if H could visit and observe in the practice she now works in. Then I asked H to come to a steering group to report first hand on some asthma work we’ve been doing together. This was her first challenge. Despite her toddler having a bit of a temperature, she surprised me by turning up, toddler in tow, dosed up with paracetamol. She spoke up and made quite an impression. D gave her a lift home and on the way told her the story of how I got her into work. H is now ready to meet that health care assistant. B is a comedian. A pretty single mum, but with a tough past. She’s loud, she swears like a Navvy and she makes the small group of mums at their coffee morning laugh with all her antics. But she thinks she’s thick. She told me so. After several occasions of sitting with her over coffee I told her she wasn’t thick and would she go with me to a tiny venue where I would perform some poetry I’d written and she could tell a joke. She looked horrified and refused. I’d forgotten to ask her for her help- to be my audience, to hold my hand. I missed her that night. I don’t always get it right. J met me in a cafe. He was one of several fathers who I planned to rope into judging a children’s competition to find the best dad in town. He was so bundled up in his hoodie I could barely see him. He had an adulthood full of agoraphobia and post traumatic stress. He called that cafe his ‘last chance saloon’. Nothing had fixed his mental problems so far, but he really liked our project engagement worker, from a similar background, who spoke to him like a mate who cared.J did the judging for the competition but come the day of the grand finale he didn’t turn up. He’d lost his nerve. He disappeared for weeks and the engagement worker found him and made sure he was ok. J started following the engagement worker around and I watched his boundless personality with people he knew. He could engage them with just one sentence. J is naturally likeable, relaxed and friendly and he openly speaks about his problems which encourages reciprocity. So I asked him to come and observe a board meeting at our HQ in the hope that a) he would travel to overcome his agoraphobia and b) he would get a chance to tell the board about our work together. He refused the lift I offered him and drove himself the 7 miles to our HQ. He arrived safely and told a surprised board that it was the first time he’d travelled alone out of his home town in a dozen years. Ever since that moment our board has backed our project to the hilt.When our engagement worker left, J applied for his job, the first job he’d been interviewed for in 13 years. He’s worked with me for 2 years now and travels round the country with me to present our work. He no longer needs his GP or mental health services. His 3 children have a different dad now.So you see, there is something beyond health improvement to address health inequalities and at New NHS Alliance we call it health creation. It’s characterised by 3 Cs: control over your life, contact with others and building confidence.There is a longer paper explaining health creation on our website. It is about finding and building strengths, not just fixing problems. And in the process it’s about stretching and challenging those residents. It’s about building relationships not just delivering factory-farmed illness services. It’s about professionals pointing people towards meaning and purpose in their lives. Here I talk about nursing, but this is just as relevant to workers in housing for example. I think all public health nurses know this and some of them used to practise in the same way that I do now, in the old days, before activity was the only currency in town and before they barely had time to run from one appointment to the other.Just as Buurtzorg is about self-managed teams of district nurses, I think we should have ‘free-range’ public health nurse teams too. Give public health nurses back their freedom, so we can give our communities hope and lead them towards meaningful work, which is a fundamental determinant of wellbeing. Work gives pride and purpose. It gives you more choice and control over your life. And it can build a different future for the next generation. Heather Henry is an independent public health nurse, Queen’s Nurse and co chair of New NHS Alliance. You can join New NHS Alliance for free here.

NHS Collaborate is delivered in partnership by the New NHS Alliance, the National Association of Primary Care, The Nuffield Trust and Salix & Co, a specialist communications consultancy.The overall purpose of Collaborate is to develop leadership, especially clinical leadership in primary care provider organisations. The three main components of this are:Identification: of current leaders, of emergent leaders and of the leaders of the future.Support: we understand that leadership can feel a lonely place, especially when there is so much negativity, as per the present.Connect: Connecting leaders to each other and to decision makers.Why is this needed? There is wide spread agreement that leadership is vital for transformation and change, yet there is no national leadership programme for primary care service providers. Secondly, what current leaders have told us is that “off the shelf” development courses did not meet their needs. Being told how to chair a meeting, what the governance requirements are for organisational directors and how to interact with the public and the media doesn’t address their emotional needs, their sense of isolation, their fears and their feelings of sometimes being completely overwhelmed by events around them.Collaborate has therefore been specifically designed for leaders, by leaders. It is there to maximise talent. It is there to support people who want to make a difference, people who want to be exceptional and not ordinary. It is there for people who want to be brave. The initial phase of Collaborate, April to June 2016, has purposely focused on leaders within a small number of vanguard sites. The intention is then to rapidly spread learning to other vanguards and non-vanguard providers, in order to support and accelerate the change process. What we’ve learned so far in conversations with those leaders is that the qualities required of our current leadership are things like courage, resilience and confidence. These qualities are hard to sustain when there are so many people willing to kick you for not seeming to be perfect, whilst failing to recognise the many small innovations that really do make a difference. To say “thank you” and “well done”. There was a feeling that help was needed to keep their energy levels up, to act as “stretcher bearers” after a knock and to share their fears and anxieties in a safe environment. Despite this, there is a genuine willingness and enthusiasm for change amongst current leaders, a real desire to make a difference.Current leaders are experiencing a whole range of emotions, some very positive, such as courage, passion and desire. These, however, are balanced by feelings of doubt, fear and anxiety. Phrases that have been used include being “in at the deep end” and “in the firing line”.Collaborate will deliver that support. It will also allow leaders to learn from the experience of others and to keep checking on the relevance of their vision and core assumptions. Collaborate will also deliver a strong and influential ear for professionals and providers in primary care. It will establish a long term relationship between NHS England and the leading membership organisations for primary care providers. The next step for Collaborate is the setting up of a learning community to support and connect leaders. This will be a virtual platform, using innovative communication channels. A Face Book page and Whatsapp group have already been set up. This learning community is available not just to those within vanguard sites but to all individuals and organisations who want to make a difference. We want and need leaders in primary care provision to be brave, to be courageous and to be exceptional. We need our leaders to inspire. We need our leaders to give hope. Front line clinicians and staff are demoralised and dispirited. Threats of mass resignation only adds to that despondency. Our patients often feel helpless and hopeless. This is then magnified by those same emotions being echoed in the front line workforce.We need our leaders to be inclusive, to support and encourage staff to develop a vision for primary care that they themselves can deliver. Hope and vision cannot be commissioned. We need leaders from within provider organisations to inspire that hope. To be brave.The following individuals make up the core faculty of CollaborateDr Jonathan Serjeant, clinical director, BICS, programme lead, NHS Alliance AccelerateDr Phil Yates, chair, GP Care , chair, NAPC NAPO (National Association of Provider Organisations) Sarah Wrixon, communications director, NHS Alliance, former national communications lead, NHS Working in Partnership Programme, founder Salix & CoJake Arnold-Forster, chair COBIC, former CEO, Dr Foster IntelligenceDr Dharini Shanmugabavan, south London GP, deputy medical director, central London Community Healthcare Trust, member of NHS Alliance National Executive
Jane Cryer, Faculty of Medical Leadership and Management, GP development in federations / new models of careDr Jane Povey, Faculty of Medical Leadership and ManagementDr Mark Spencer, Fleetwood GP, co-chair, New NHS Alliance Dr Michael Holmes, York GP, chair Humberside Faculty, RCGPDr Minesh Patel, East Grinstead GP, clinical chair, NHS Horsham, vice-chair, NAPCDr Peter Devlin, Brighton GP, co-founder Brighton & Hove Integrated Care ServicesDr Phil Ridsdill Smith, GP Partner, Haslemere Health Centre and former adviser to SoS for Health
Dr Rebecca Rosen, south east London GP, senior fellow, Nuffield TrustDr Robert Varnam, Manchester GP, head of general practice development, NHS EnglandUna Nicholson, independent facilitator for BICS and specialising in the NHS

Ok, so if you have never seen Star Wars (firstly shame on you), then you may get a little lost. I can assure you though that as ‘protectors of the galaxy’ Jedis are basically nurses with light sabres. From being a small child I have connected deeply with Star Wars, so much so that I genuinely think I have an issue. In terms of fan level I’m your PHD geek. Contemplating this as an adult and student nurse/ padawan, I can see that the story line is based on a need for every day heroes. Heroes who stand up for what they believe in to bring balance and harmony to the galaxy/ community. Heroes that defend regardless of consequences. Heroes that fight for the good of people they may never have met. A battle fought against those that wish to dismantle all that is good for their own gain; by manipulation, overpowering, and dictatorship. Sound familiar?So, ‘The Force’. For those of you unfamiliar with the concept, The Force (in Star Wars terms) is an energy that flows through everything and everyone. It binds us together, our very being and energy if you like. Jedi /nurses are able to connect to it and understand wider concepts of the galaxy/ society through emotional intelligence; in nursing terms our ‘holistic eyes’.Sith are the bad guys who bare striking similarities to our own un-named opposing organisations. They have the ability to understand these concepts but are driven by different goals, goals that serve themselves. Many Sith started out as Jedi, but with progression of their power they lost sight of what was good, what was important. They used their skills and wisdom for manipulation instead of collaboration. United in their detachment from the underlying basics of what was right, the bad guys became ‘The EMPIRE’ and the Empire entered into direct conflict with the Jedi.For anyone with an iota of Star wars knowledge, please forgive the simplicity of my overview. To everyone else, you need know only this. Jedi did not apply to UCAS for a course in their chosen profession. They found their calling and often resisted it in the early days. Personally I can relate to this wholly. I found being a nurse by chance. Life literally brought me here. True Jedi are more than the skills that they learn. The best of them have an unmatched underpinning wisdom that is not taught, but achieved through their own desire to prevail against the odds. I can directly liken this to the holistic assessment, collaboration, and care required for our patients. The balance of the Force itself, relies on reciprocity. It MUST feed us inwardly in order to support our empowerment and healing of others. Like the Jedi, nurses must seek to self-care as much as we give to others. There has been a disturbance in the force and dark times in our NHS, but light WILL shine through. Good will prevail. Because the true nurses/ Jedi among us will not give up. We will rise up against the Empire. Our galaxy/ NHS is depending on us. We are needed more than ever to advocate. So stand tall Jedi/ nurses. With your light sabres/ dressing packs at the ready. Because I am yet to see a film where the bad guys win. I for one can’t wait to receive my pin number/ light sabre and join the Rebel Alliance.And on a final non Star Wars related note: the weed is the fastest growing plant in the flower bed. It can overcome the beauty and sustenance growing there and once sown is almost impossible to eradicate. So plant healthy beautiful seeds, for your colleagues, for your patients, and for those that oppose your positive abilities to be exceptional. May the force be with you…alwaysP.S Star Wars fans: to date I have resisted requesting FBC’s, U & E’s and a full Midi- Chlorian count, but if you have the guts… I actually dare you!Naomi FlemingStudent NurseBirmingham City University

I read NICE Guidance (NG19) – Diabetic foot problems: prevention and management. It comes after attending a diabetes meeting in which I had to walk past 135 single shoes to get to my seat. That is a powerful message to identify that we must try and reduce the number of amputations.
Everyone knows that prevention is better than cure and a good routine foot care program is essential for everyone with diabetes. I thought it would say – ‘let’s get sorted early’ – catch people before they have problems and get them into a routine. A simple routine – check your feet, wash and dry, moisturise daily and attend your routine foot check appointments.
The Society of Chiropodists and Podiatrists wrote a guide to maintaining healthy feet for people with diabetes. It is very clear and helpful and I would recommend it. It says ‘check your feet, wash with warm water and soap and moisturise. It recommends that the patient should ask their pharmacist for a moisturiser.
Many patients do not maintain the routine for more than a couple of weeks. There are simple issues coming into play here – the greasiness of the product (time to put socks and shoes on, risk of falling and staining of bedlinen) – the ease of application and what you do between the toes. It is not rocket science – just takes a little time and thought.
So, I expected a small reference to pharmacists – in the choice of product with the patient, emphasising the importance of routine care and some monitoring – you know – ‘how are you getting on with that cream?’
We know of over three million patients with diabetes in the UK. It’s a big job. So I saw an important role for community pharmacists – you know the guys that have a pharmacy on the high street or in the shopping complex or the supermarket – the ones that see patients with diabetes that are treated with medicines 13 times a year – the ones that have had a relationship with these people before and during their diagnosis – a common threat in patients’ lives.
But no – not a mention. In a time when integrated care is a buzzword – commissioners are expected to commission a bigger and better service ignoring the community pharmacists who already have a relationship with the patients.
I do ask myself why. But I look at the ‘expert reference group’ – is there a pharmacist – obviously not. Was there reference to the work of community pharmacy in the stakeholder comments – well no. Isn’t it a sorry state of affairs?
However, you will be pleased to know that many community pharmacies offer routine foot care advice to their customers. They may sell nail clippers and appropriate moisturisers and emphasise the importance of checking feet, attending routine appointments and contacting an appropriate healthcare professional if things change. They will be supporting self-care, offering advice and encouragement and matching products to patient’s experiences and needs.
We should be changing just a small part of our focus to prevention and creating health – rather than only focusing on illness and salvage. At least community pharmacists understand this.